Laserfiche WebLink
' APPLICATION FOR PERMIT s �:jf�f�•�,: �r`, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTONON AVE-, STOCKTON, CA I <br /> Telephone (209) 466-6781 ` <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work herein <br /> cation is <br /> madle int <br /> compliance with Sano <br /> oJoaquin Couthe San nty O d nalncle Nto.549 for sewage orealh District for a 'No. 1862 for t to cwell/PUMP and the Rules and Regulations of he Sans Joaquin <br /> Local Health District. <br /> / r City Lot Size PM <br /> Job Address / <br /> rAddress Phone <br /> Owner's Name <br /> I Contract , <br /> Address Jam( / �- r yL / License No. Phone <br /> ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LD DESTRUCTION El C <br /> P INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ <br /> i SEWER LINES DISPOSAL FLD. - =PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TA <br /> FOUNDATION (CULTURE WELL OTHER WELL PITS/SUMPS <br /> UCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well Casing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ex n <br /> Type e of Casing Specifications <br /> I` <br /> 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy yp ¢e of Grout <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> Approx. Depth t I Eastern Surface 5.eal Installed by <br /> I 1 Irrigation - <br /> k H P State Work Done <br /> k Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION t 1 REPAIR/ADDITION [ 1 DESTRUCTION available rwi h .)in 200 feetstem permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other��- <br /> f Number of living units: Number 6f-bedrooms <br /> i Water table depth <br /> Character of soil to a depth of 3 feet: L- <br /> Capacity No. Compartments <br /> t SEPTIC TANK ❑ Type/Mfg - <br /> Method of Disposal _ <br /> j PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> } LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica t must call for all requir Inspections. Complete drawing on reverse side. <br /> Title: Date: <br /> Signed <br /> r FOR DEPARTME T USE ONLY <br /> f Date J Area C/ <br /> Application Accepted by <br /> Pit or Grout Inspection by p �j d, <br /> Date Final Inspection'by DateWIS <br /> L <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ danieca 823-7104 ❑ Tracy 835-6W5 <br /> r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> � +.EH 13-24(REV.I/rssl <br /> 3s;a v �� <br /> 1' <br /> EH 14-2a <br /> ' e <br />